File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL
APPLICATION TO
REVIEW DECISION ABOUT OCCUPATIONAL REGISTRATION, LICENSING OR DISCIPLINARY ACTION*
		
	*for applications under authorising laws noted on attachment		

APPLICANT’S DETAILS	
Name	 	
Occupation/Profession

	 	
Address Line 1	
 	
Address Line 2	
 	
Telephone
	
Email:                                                          Fax:	
APPLICANT’S REPRESENTATIVES DETAILS (IF ANY)	
Name

Address Line 1	
 	
Address Line 2	
 	
Telephone 
	                                                                    
Email:                                                          Fax:	
DECISION MAKER’S DETAILS	
Name of Decision Making Entity	 	
Address Line 1	
 	
Address Line 2
		
Contact Officer:

Telephone

Email:                                                          Fax:                                       	
What decision do you want to appeal or have reviewed (attach a copy of the decision)	

	
	
Date Decision Made                                                     Date You Received Decision

	

Law under which your application is brought (a list of authorising law is attached)	

	
*The applicant and respondent have made no prior attempts to resolve their disputes	

Reasons for applying for review (use an attachment if insufficient space. Further details can also be provided in an accompanying affidavit or  statement)	

	

	

	

	

	

	

	
	
Applicant’s signature		Date		

INFORMATION ABOUT USE OF THIS FORM

This Application form should be used for applications to the ACT Civil and Administrative Tribunal (the ACAT) to review a decision to refuse to give or to renew, or to place conditions on, a licence or registration under the laws set out below.  It can also be used to appeal a decision to dismiss a complaint. 

ACT Teacher Quality Institute Act 2010
Agents Act 2003
Architects Act 2004
Board of Senior Secondary Studies Act 1997
Casino Control Act 2006
Construction Occupations (Licensing) Act 2004
Clinical Waste Act 1990
Fair Trading (Motor Vehicle Repair Industry) Act 2010
Fisheries Act 2000
Gas Safety Act 2000 and Gas Safety Regulation 2001
Hawkers Act 2003
Health Practitioner Regulation National Law (ACT) Act 2010 [applying the Health 
Practitioner Regulation National Law (ACT)]
Legal Profession Act 2006    
Liquor Act 2010
Medicines, Poisons and Therapeutic Goods Act 2008
Race and Sports Bookmaking Act 2001
Sale of Motor Vehicles Act 1977                                    
Security Industry Act 2003 
Surveyors Act 2007
Tobacco Act 1927
Water Resources Act 2007

A copy of the relevant decision should be attached to the application. The application should also have an affidavit or an attached statement setting out the reasons for challenging the decision in detail if the application form does not have enough space. The affidavit or statement should attach copies of documents that further explain the basis for the application and/or grounds upon which the applicant seeks to rely.